Intestinal malrotation and volvulus in adult life

INTRODUCTIONMidgut volvulus due to intestinal malrotation is a rare cause of intestinal obstruction when occurring in adult life. This paper documents the difficulties in reaching an early diagnosis.PRESENTATION OF CASEWe describe the case of an 85-year-old man with non-specific abdominal complaints for 20 years, who presented with sudden onset central abdominal pain. An acute median laparotomy under general anaesthesia was performed during which a 360° clockwise rotation of the small bowel around the mesenteric pedicle of the superior mesenteric artery and vein was found.DISCUSSIONMalrotation is considered any deviation of the normal rotation of the midgut in embryological development, causing intermittent episodes of gastrointestinal obstruction or acute events of midgut volvulus. Although mainly a paediatric diagnosis, some cases do present in adult life. Radiologic investigations include: upper gastrointestinal contrast studies, Doppler sonography and a contrast enhanced CT of the abdomen. If a true malrotation is diagnosed or found by coincidence, a Ladd's procedure is advised, even if the patient is asymptomatic. There is no proven surgical strategy for preventing the recurrence of small bowel volvulus in case of malfixation of the midgut.CONCLUSIONNon-specific recurrent abdominal complaints in adults of any age should raise suspicion of the possibility of a midgut malrotation or malfixation with or without intermittent volvulus. This case highlights the importance of diagnosis in an early stage.     

Delayed presentation of familial intestinal malrotation with volvulus in two adult siblings

Intestinal malrotation is an uncommon cause of abdominal pain and normally presents during infancy. Familial cases of malrotation are extremely rare in the absence of other congenital malformations. We present the case of a 22-year-old woman with undiagnosed chronic abdominal pain and her previously well 16-year-old brother who presented within 18 months of each other with acute midgut volvulus secondary to intestinal malrotation. Clinicians should be aware of this rare but serious cause of abdominal pain.     

Laparoscopic repair of acute volvulus in a neonate with malrotation

This report describes the laparoscopic repair of acute volvulus in a neonate with malrotation.     

Gastrointestinal malrotation with volvulus in an adult

Case presentation and literature review for intestinal malrotation presenting in an adult. Although the number of patients with this condition that escape infancy undiagnosed is not clear, it is clear that when the rare patient presents as an adult it can be a perplexing situation for surgeons not familiar with the presenting signs and anatomy. This confusion can lead to diagnostic and intraoperative errors.     

Acute midgut volvulus following laparoscopic cholecystectomy

A case of midgut volvulus forty eight hours following laparoscopic cholecystectomy is reported.     

Three recurrent episodes of malrotation in an infant

Malrotation with midgut volvulus in a newborn is not a rare condition and Ladd's procedure is the recommended surgical treatment. Recurrent volvulus after Ladd's procedure is very rare. We present a case of an infant operated on after birth for malrotation and midgut volvulus with 2 recurrent similar episodes in the following 20 months. We recommend abrasion of the parietal and visceral peritoneal surfaces when recurrence of malrotation occurs.     

Colonic volvulus in an adult after childhood Ladd's procedure for malrotation

Malrotation and volvulus are encountered early in infancy and sometimes later in childhood, but rarely in adulthood. This ailment is treated through Ladd's adhesiolysis, detorsion, and possibly bowel resection. Literature is scarce on the long-term outcomes of this procedure, especially into adulthood. We present a case report of an adult female with a history of a laparotomy as a child for a bowel obstruction secondary to malrotation, presenting with an obstruction and colonic volvulus, secondary to an adhesive band, requiring emergent surgery. The patient did well postoperatively without complications. In adult patients presenting with a bowel obstruction and a consistent history in childhood, recurrence of volvulus should be considered as part of the differential diagnosis through a detailed history and assessment.     

Small bowel volvulus with no malrotation after laparoscopic appendicectomy: Case report and literature review

INTRODUCTION

Small bowel volvulus, as a complication of laparoscopic surgery, is a rarely reported clinical entity. We present a case of a young female who developed small intestinal volvulus after laparoscopic appendicectomy. She had this complication in the absence of malrotation or other previous abdominal operations.

PRESENTATION OF CASE

A 17-year-old woman presented with acute appendicitis. After an uneventful laparoscopic appendicectomy, she developed acute small intestinal obstruction on the second post-operative day. A prompt laparotomy showed small bowel volvulus, which was reduced, with no evidence of malrotation. She had an uneventful recovery and was discharged within 3 days of the second operation, in a stable condition.

DISCUSSION

This article presents a review of the literature of this rare cause of small intestinal obstruction after laparoscopic surgery, stressing on the importance of early diagnosis and treatment. A discussion of the potential factors predisposing to this entity is presented, emphasising the need of a higher-evidence study as to its aetiology and prevalence.

CONCLUSION

Small bowel volvulus is a rare complication of laparoscopic surgery, but its early diagnosis and prompt treatment is essential to avoid morbid outcomes. Surgery is the therapeutic mainstay.     

A case of midgut volvulus related to adult intestinal malrotation found with weight loss after streptococcus infection: A case report and literature review

Introduction and importanceThe incidence of intestinal malrotation is 1 in 6000 births, and 90% of cases occur within the first year of life. Adult cases are rare, with a reported incidence of 0.2%–0.5% of all cases. The significance of reporting this case is to recognize that some adult-onset cases require surgery even in the absence of intestinal necrosis.Case presentationA 36-year-old man was infected with streptococcus and treated with antibiotics. He developed appetite loss and his weight decreased 12 kg in 4 months. His abdomen was flat and soft with no tenderness. A computed tomography scan showed that the horizontal duodenal leg was not anchored to the retroperitoneum. Rotation of the mesentery, which was wrapped around the superior mesenteric artery in a clockwise direction, was observed, suggesting midgut volvulus. We performed emergency surgery and Ladd’s procedure.Clinical discussionA previous study reported that the most common symptom in the chronic course of intestinal malrotation was abdominal pain in 41.2% of cases, and weight loss was observed in only 2.6% of patients. The high degree of intestinal adhesion suggests that repeated torsion and release and the development of collateral vessels may have contributed to the asymptomatic course.ConclusionAdult-onset intestinal malrotation should be considered as a differential diagnosis in the presence of weight loss and gastrointestinal symptoms. The timing of surgery is still controversial. In chronic cases, severe adhesion might be expected and laparoscopic surgery should be considered carefully.     

Long-term outcomes of ultrashort bowel syndrome due to malrotation with midgut volvulus managed at an interdisciplinary pediatric intestinal rehabilitation center

PurposeThe purpose of this study was to describe long-term outcomes of pediatric-onset ultrashort bowel syndrome owing to midgut volvulus managed at an interdisciplinary intestinal rehabilitation center.MethodsPatients with a history of malrotation and pediatric-onset midgut volvulus causing extensive bowel loss (< 20% residual small bowel length expected for postconception age) and treated between 2010 and 2017 were reviewed. Data are expressed as median (IQR).ResultsTwenty-three patients had midgut volvulus at age 1 (0–21) day leading to 9 (8–12) percent predicted residual bowel length. Eight (35%) had gastroschisis. Follow-up was 8.5 (6.6–12.2) years from volvulus. Five (22%) patients underwent intestinal/multivisceral transplantation, and all achieved enteral autonomy. Eighteen (78%) patients remained transplant-free, 7 of whom achieved enteral autonomy after 718 (682–1030) days of parenteral nutrition. Transplant-free enteral autonomy was achieved by 0/6 patients with gastroschisis, compared to 7/12 without gastroschisis (p = 0.04). For the overall group, 18 (78%) patients had small bowel bacterial overgrowth, and 7 manifested symptomatic D-lactic acidosis. We observed 2 mortalities, one awaiting transplant and one 4 years following transplantation.ConclusionMidgut volvulus owing to malrotation with extensive bowel loss is associated with favorable long-term survival. Transplant-free enteral autonomy may be feasible, particularly in the absence of gastroschisis.Type of studyPrognosis study.Level of evidenceIIb, retrospective cohort study.     

A rare presentation of midgut malrotation as an acute intestinal obstruction in an adult: Two case reports and literature review

INTRODUCTIONMidgut malrotation is a congenital anomaly presenting mainly in the childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually recognized intra-operatively, therefore a high index of suspicion is always required when dealing with any case of acute intestinal obstruction.PRESENTATION OF CASEWe report two cases of young adults who presented with symptoms of acute intestinal obstruction and were diagnosed intra-operatively as cecal volvulus and paraduodenal hernia, respectively, caused by midgut malrotation. Post-operative CT scan confirmed these findings.DISCUSSIONMalrotation of the intestinal tract is a product of an aberrant embryology. The presentation of intestinal malrotation in adults is rare (0.2–0.5%). Contrast enhanced CT can show the abnormal anatomic location of a right sided small bowel, a left-sided colon and an abnormal relationship of the superior mesenteric vein (SMV) situated to the left of the superior mesenteric artery (SMA) instead of to the right.CONCLUSIONAnomalies like midgut malrotation can present as an operative surprise and awareness regarding these anomalies can help surgeons deal with these conditions.     

Congenital diaphragmatic hernia with gastric volvulus

Gastric volvulus is a surgical emergency presenting in various forms. Association with diaphragmatic defect is well known. Here we describe three cases of gastric volvulus associated with diaphragmatic defect having varied presentations and their management. A rare case of gastric volvulus with complete gangrene of the stomach is also reported. Three types of gastric volvulus have been described depending on the rotation axis: organoaxial, mesentericoaxial and combination of both types. Operative treatment includes reduction, correction of underlying cause and gastropexy.     

Laparoscopic cholecystectomy for gallbladder volvulus

Torsion of the gallbladder is a rare entity. Approximately 300 cases have been reported since it was first described in 1898 by Wendel (Ann. Surg. 1898; 27:199). The condition occurs most often in the elderly. Although the etiology is unknown, a constant finding is the presence of the gallbladder on a mobile mesentery (floating gallbladder). Torsion, or volvulus, of the gallbladder occurs when this gallbladder twists axially, with subsequent occlusion of bile and/or blood flow.We present a case of gallbladder volvulus diagnosed and treated laparoscopically. This is the first reported laparoscopic cholecystectomy for volvulus of the gallbladder.     

Outcomes after a Ladd procedure for intestinal malrotation with heterotaxia

Purpose

Intestinal rotation abnormalities and complex congenital heart disease associated with heterotaxia coexist. Despite the risk for midgut volvulus, performing a Ladd procedure for asymptomatic malrotation with heterotaxia remains to be controversial because the presumed risk for postoperative complications is thought to exceed the benefits of the operation. The purpose of this study was to review the incidence of complications after a Ladd procedure in asymptomatic patients with heterotaxia to guide recommendations for this patient population.

Methods

The medical records of all patients with heterotaxia who underwent a Ladd procedure for asymptomatic malrotation between 1984 and 2004 were reviewed. Type of cardiac disease, postoperative complications, and survival were recorded.

Results

Twenty-two patients (9 boys and 13 girls) with heterotaxia underwent an elective Ladd procedure after their medical stabilization or surgical correction or palliation of their cardiac anomaly. Of these patients, 19 were younger than 1 month at the time of the operation. The remaining 3 patients underwent the operation when they were between 2 and 5 months old. Three of the 22 patients (14%) developed postoperative intestinal obstruction: lysis of adhesions was performed in 1 patient; another patient required a staged bowel resection for a closed loop obstruction; and yet another patient had recurrent midgut volvulus 4 years after an incomplete initial Ladd procedure. All patients survived the initial and secondary procedures. Four deaths, all more than 1 month after the surgery, occurred as sequelae of the underlying cardiac anomaly. Length of follow-up ranged from 1 to 17 years.

Conclusions

We report on a 14% risk of postoperative bowel obstruction after an elective Ladd procedure, as compared with a small but significant incidence of midgut volvulus in patients with malrotation in the setting of complex congenital heart disease. Our results support the conclusion that an elective Ladd procedure at a time of relative cardiac stability for selected patients with heterotaxia has an acceptably low morbidity and should be considered to prevent midgut volvulus.     

Small bowel volvulus resulting in infarction due to an anterior gastropexy band.

Volvulus of the small bowel, although rare, carries a high risk of strangulation and ischemic necrosis. It is usually caused by the rotation of a loop of small intestine around an adhesion band or stoma. We present a case of an anterior gastropexy band, giving rise to a small bowel volvulus, necessitating resection due to infarction. This band resulted from separation of the most distal anterior gastropexy suture from the anterior abdominal wall. The distensible nature of the stomach and its resultant postprandial gain in weight produced tremendous shearing forces on the gastropexy sutures, and, as our case demonstrates, a greater number of gastropexy sutures does not protect against this complication.     

Assessment of care timelines in intestinal malrotation with volvulus: A retrospective chart review

BackgroundPatients with intestinal malrotation with volvulus (MWV) may suffer bowel ischemia, which can be correlated with the timing of surgical intervention. The purpose of this study was to identify and assess time-blocks in the care of patients from initial physician assessment (IPA) to surgical intervention to highlight potential opportunities for improvement.MethodsRetrospective chart review of patients with MWV presenting to McMaster Children's Hospital between January 1st, 2000 and December 31st, 2020 (n = 31). Demographic data and time-blocks of care were identified and analyzed (p < 0.05 considered significant). All times were reported as medians.Results22 males (71%) and 9 females (29%) were identified; median age was 9.8 d. IPA to incision was 10.7hrs and surgical consult to incision was 3.4hrs. Time to incision for patients <1 y was not significantly different than those >1 y (10.5hrs vs 10.7hrs, p = 0.737). The use of ultrasound did not significantly affect time to incision (7.9hrs vs 12.0hrs, p = 0.128). For patients requiring resection or having pan-necrosis there was no significant difference in time from IPA (10.9hrs vs 10.5hrs, p = 0.238) or surgical consult to incision (4.0hrs vs 3.3hrs, p = 0.808).ConclusionTime from IPA to surgical consult and time from surgical consult to surgical intervention represented the largest proportions of time. Age, use of ultrasound, and need for resection or having pan-necrosis did not significantly affect the time to incision. This data may be used to inform opportunities for expediting the management of patients with MWV once they have presented to a physician.Level of EvidenceIII.